Arlt et al. analysed the urine steroid metabolome in 174 newly diagnosed patients with primary aldosteronism (PA). The eye-catching data concern the high prevalence of glucocorticoid production in this cohort, as measured by urinary steroid profile (USP).

Because of this finding, 46 patients were investigated in more detail. A few of these individuals had abnormal overnight dexamethasone suppression test (ONDST) preoperatively (data not given). However, 29% failed a standard 30-minute short synacthen test (SST) at 10–14 days post-surgery, some having a 30-minute cortisol after synacthen of 200nmol/l. The authors did not report whether this was associated with clinical features of adrenal insufficiency postoperatively. As dexamethasone (8mg) is used as an anti-emetic in some anaesthetic protocols, this may have, in part, protected from this.

These data suggest, therefore, that a significant number of patients will have adrenal insufficiency post-adrenalectomy for PA, and we should be alert to this clinically. It is not clear how we should screen preoperatively, as ONDST did not seem to identify this cohort. Should we therefore obtain a USP in all patients with mineralocorticoid excess to identify this cohort, followed by an SST post-operatively? Or would a 9.00am cortisol measurement several days post-operatively predischarge be sufficient in the first instance? Food for thought…

Read the full article in JCI Insight 2 e93136 (OA)